When 21-year-old Alexa, a student from Los Angeles, speaks about her battle with cutting, she uses the dark language of progressive drug addiction. “I started when I was 19,” she says. “At first, it was very shallow cuts along one specific area of my wrist—just slightly more than a scrape. But as I continued, it progressed. They began going up and down my arms. Within a few months, I had to start going to the hospital and getting stitches for it. After a year, I basically ran out of room on that part of my body.”

For the past decade, cutting has been working its way slowly into popular imagination and in lurid headlines—thanks, in part, to teen icon Demi Lovato. It’s even crept into mainstream television: Dr. House, after all, cut himself to get a fix while attempting to kick Darvon. Although few studies have been published on the subject, it’s estimated that one in every 200 American girls between the ages of 13 and 19 cut themselves regularly, while as many as four percent of adults in the US engage in similar self-harm.

According to Dr. Paul Hokemeyer, a sober doctor who has appeared repeatedly on Good Morning America and specializes in the topic, cutting is an impulse-control disorder—a psychological term loosely defined as the inability to resist acting on impulsive thoughts and often characterized by the intentional harming of oneself. Usually associated with trauma, cutting doesn’t start at any set age but, culturally speaking, tends to be associated with the pain of adolescence.

It’s also as addictive as a narcotic.

Because of the shame, there’s often a lack of awareness about the behavior—even among medical professionals.“When a person cuts, it calms them down, and that registers in the brain as a calming mechanism,” says Hokemeyer. “Once that happens, it's a behavior that they will always be drawn to for the rest of their lives."

Cutting is calming, according to Hokemeyer, because “the body releases endorphins, which are the body’s narcotic: they minimize pain by providing a sense of well being.” When our bodies experience pain, Hokemeyer explains, our brains release endorphins to soothe and energize us so we can take action to get out of harm’s way. “The pain switches from being emotional to physical,” he says. “The person sees blood coming out and thinks, ‘How great and absolute.’ And that’s satisfying on a certain level because physical pain eventually goes away while emotional pain feels as though it won’t—and it’s that uncertainty which is so unsettling. The devil you know is better than the devil you don’t.”

This description certainly rings true for Alexa. “When I’m in a lot of emotional pain, I get lost and disassociated,” she says. “Cutting calms me down and brings me back into reality. It’s very similar to smoking cigarettes—but I obviously didn’t cut as often as smokers smoke. I would usually only cut once a day, and it could last anywhere from a few minutes to a few hours.”

But what Hokemeyer and Alexa view plainly as an affliction is actually the subject of intense debate and disagreement within the medical community. Cutting falls under the umbrella term of “non-suicidal self-injuries” (NSSI's), but medical experts are divided on whether the act is para-suicidal—meaning that it leads to a risk for suicide—or not. “To me, cutting plays into the risk factor for suicidality because many cutters suffer from borderline personality disorder and poor impulse control,” Hokemeyer says. “They just feel everything so intensely and find it so difficult to address emotional discomfort.” Another point of discrepancy: while some doctors and psychologists believe that cutting is a chronic condition that cutters will have to struggle with their entire lives, others say that it’s a compulsion that is possible to fully recover from.

“Cutting is more of a compulsion than an addiction,” says Christopher Murray, a New York City-based clinical social worker who works with people in recovery. “Addictions are physiological in that the body develops tolerance to an external substance, while compulsions are behaviors that are obsessive in nature. There are no external substances associated with cutting.”

While Hokemeyer agrees with Murray’s assessment that cutting is a compulsion, he also maintains that it’s an addictive behavior. “There’s no definition of addiction in any diagnostic manual, but those of us who treat addiction look for the three C’s: craving for the substance, loss of control once the thought to use arises in the mind of the person and continued use in spite of negative consequences,” says Hokemeyer. “The object of one’s addiction can therefore be anything that changes their emotional state.”

But recovering from an addiction to cutting isn't as simple as conquering other addictions. Not only is it less prevalent, there’s also a complicated shame factor. In many communities—say, Los Angeles—getting sober is no longer as ghettoized as it once was, in part because of the growing number of people in recovery. But it can be difficult for cutters to find anyone who can identify with their condition, and they’re often met with disdain from their peers when they talk about it. They tend to hide their behavior out of something like embarrassment. They often wear long-sleeve shirts, which can cause the cuts to fester.

The medical community isn't immune to the common misconceptions of cutting. “When I was 15, I told my therapist that I cut myself and she broke patient confidentiality,” reports Alison, a 20-year-old student and manager at a cell phone store from Sarasota, Florida. “She ended up having my parents come in because she thought I was going to kill myself, even though that was never the intention. They freaked out and put me in a psych ward. I talked to the therapist a couple of years later and she admitted doing that was a mistake. It just made me realize that you have to watch out who you tell.”

A year later, when Alison had reconstructive scar surgery because of her wounds from cutting, she said the response from doctors and nurses at the hospital was equally unsympathetic. “They kept asking what was wrong with me and why I would do this to myself,” she recalls. “They treat you like you’re stupid. They don’t say that directly, but their behavior towards you reflects that.”

According to Hokemeyer, this sort of attitude is among the biggest problems in treating self-injurious behavior. “People tend not to understand that cutting is used as a solution to a patient's emotional pain,” he says. “Some people see it as a moral failure. There’s a huge amount of stigma that adds to the problem. Cutters are treated like second-class citizens.”

An additional issue when it comes to treating cutters is that while there are three common therapies that have proven to be successful, they all deal with the issues related to why a person might cut and not the act itself.

Cognitive behavioral therapy (CBT) looks at the self-loathing and self-critical behavior of cutters, and tries to help them catch when these cognitive distortions, or harsh perceptions of reality, occur. “An example might be if they see a friend at a party and the friend turns away,” says Hokemeyer. “There’s a snowball effect where the person starts to think, ‘Oh my God, she hates me, I’m worthless, everybody thinks I’m an asshole. I’m going to die alone.’” Dialectical behavioral therapy (DBT) involves holding and processing uncomfortable emotions—which addresses the typically poor impulse control of cutters. Then there’s psychotherapy, which looks at the psychodynamic issues that unconsciously drive cutters, such as low self-esteem or emotionally fragility. (While SSRI’s and anti-anxiety medications are used in treatment, experts say that they have to be prescribed in conjunction with therapy in order to be successful.)

Alison tried a number of therapies—including CBT, DBT, group and talk therapy—but said she found a particular connection with a website called To Write Love on Her Arms because it connected her with a community of like-minded people. This makes sense to Murray. “Something as simple as third-party validation can be extremely helpful in these cases,” he says. “Cutters can talk to their parents about it—but if they will panic unnecessarily, talking about it with a friend can also provide the same benefits. Meditation or writing in a journal can also be effective.”

Ultimately, overcoming cutting—like overcoming drug addiction and alcoholism—is a work in progress. Both Alexa and Alison are currently in treatment for their disorder—Alexa through a therapy called mentalization that involves one group and one individual session a week, and Alison through twice-weekly therapy (she’s also getting ready to start DBT sessions again). Although the amount of times they cut each month has decreased and they have each found various motivations for stopping (Alison is looking forward to an upcoming wedding where the bridal gowns are strapless), both confess to having cut themselves within the past 30 days. Yet they’re both encouraged by their overall progress. “Once I went through the treatment the first time, it helped me think about the consequences of my actions, like how doing this will make me feel better now but will create scars for my future,” Alison says. “I don’t feel as empty-handed now that I have the tools to distract myself.”

But despite their progress, both say they can’t imagine a time when dealing with cutting won’t be a part of their lives. “I’ve found better coping strategies, but the urge to cut hasn’t gone down and I think that I’ll always have it,” says Alexa. “It’s just like any drug.”

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